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Ssa 8000 2007
Security Administration,
and where applicable, for medical assistance under
Title XIX of the Social Security Act.
Filing Date (Month, Day, Year)
Receipt
Protective
FS-REFERRED
FS-SSA/APP
Preferred Language
Written:
Spoken:
TYPE OF CLAIM
Individual with
Ineligible Spouse
Individual
Couple
Child
Child with Parents
PART I--BASIC ELIGIBILITY-- Answer the questions below beginning with the first moment of
the filing date month.
1. (a) First Name, Middle Initial, Last...
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